The scalping forehead flap for 1-stage reconstruction of large facial defects after tumor resection

&Volume24,Number4,July2013

5.HewittDK,KinneyWC.Twocasesofincidentalepidermoidcysts:sphenoidsinusandtemporalbone.EarNoseThroatJ2006;85:825Y828

TheScalpingForeheadFlapfor1-StageReconstructionofLargeFacialDefectsAfterTumorResection

Xiao-FeiXiang,MD,BiaoCheng,MD,PhD,

Jian-BingTang,PhD,Yan-HongWu,MD,MinXuan,PhD,YanPeng,MD

Abstract:Skintumorsoftenoccurinthefaceorothersun-exposedareasintheagedpopulation,andcancerousulcerationinthefaceleadstofacialdamage.Regardingtheaestheticcharacterofthefacialunitandtheageorconcomitantpathologiesofthesepatients,itisnecessarytousequick,reliablemethodstodebridemalignantulcerandcoverthewoundorsuturetheincision.Wereport2casesoflargefacialmalignantulcerthatweretreatedwithforeheadflapbasedonthesupratrochleararteryorthefrontalbranchofasidesuperficialtemporalarteryina1-stageoperation.Bothofthemgotsatisfyingfunctionalandaestheticresults.

KeyWords:Facialcancerousulceration,thescalpingforeheadflap,1-stagereconstruct

heincidenceoffacialskintumorsisrising,andthemostcom-montumorlocationsontheheadarethesun-exposedareas,suchasthenose,forehead,cheek,andauricle.1Regardingtheaestheticcharacterofthezygomatic-temporalcheekornose,surgeonshavetominimizedistortionofthefreemarginsoftheadjacentstructuresduringoperationandhealingtoachievesuperiorresults.Withthesechallengesinmind,thisarticlediscussesthe1-stageapproachtothereconstructionofzygomatic-temporalcheekdefectsandnasalde-fectsafterlarge-areafacialtumorresection.

FIGURE1.Patient1.A,Acaseoflargedefectofthenoseandperipheraltissuesinthemidface.B,Postoperativeresultsaftertheforeheadflaprotatedandrepairedthedefect1monthafter.

adequatemargins.Second,theforeheadflapwasdesignedaccordingtothebloodsupplyandtherecipientarea.Then,wedissectedandraisedtheflapinthesubgalealplaneandrotatedittotherecipientsite.ThedonorsitecanbeclosedwitharunningW-plastyalongthehairline,combinedwithbilateralsubgalealadvancementflaps.Partial-thicknessskinobtainedfromthethighwasusedtocoverthenasaldefecton2sides.

Patient2

Patient2isa60-year-oldmanwithalargemalignantulcerontherighttemporozygomaticareaandcheekoftheface.Thetumorwasafungating,ulcerating,andinduratedmassextendingfromtheintraoraltotheexternalsurfacewithananterior-posteriorwidthof15.6cmandaheightof8.5cm(Fig.2).Thismassencroachedonthelateralwalloftherightorbital,andtherighteyeisblind.Anincisionalbiopsyshowsmoderatelydifferentiatedsquamouscellcarcinoma.

First,themalignanttumorisexcisedincludingtheperiosteumandadequatemargins.Second,theforeheadflapwasroutinelydesignedacrossthemidline,dependingonthelengthofflapneeded.Thedistalborderextendedtoalevelofthebroworlateralcanthusoftheeye.Inferiorly,theborderoftheflapfollowedtheeyebrows.Thesuperiorborderandtotalwidthoftheflapweredesignedbelowthehairline.Theflapwaselevatedbetweentheperiosteumandthegaleaaponeuroticaandrotatedtotherecipientsite.Full-thicknessskinobtainedfromtheabdomenwasusedtocovertheentireforehead(Fig.3).

T

DISCUSSION

Neoplasmsoftheskinarefoundmostoftenontheface.Malignanttumorsofthefacialskinposeachallengeintreatment,prohibitingcompromisesbetweenoncologicallyresponsiblesurgeryandfunc-tionalpluscosmeticoutcome.2Theageandconcomitantpatholo-giesofthesepatientsmakeitnecessarytousequick,reliablemethodswithsuitableregionaltissuetosolvetheproblemofthepostexcisionaldefect.

Mostfacialdefectscanberepairedusinglocalavailabletissues.However,alargecheekdefectorthetotalnasaldefectcannotbe

CLINICALREPORT

Patient1

A45-year-oldmanpresentedwithextensivecancerousulcerationofthenose,alargedefectofnoseandperipheraltissuesinthemidface(Fig.1).Thelesionmeasured7.8Â6.4cm,andanincisionalbiopsyconfirmedadvancedulceratingbasalcellcarcinomaofthehead.First,weexcisedthemalignanttumorincludingtheperiosteumand

FromtheDepartmentofPlasticSurgery,TheKeyLaboratoryofTraumaTreat-ment&TissueRepairofTropicalArea,GeneralHospitalofGuangzhouMilitaryCommand,Guangzhou,PRChina.ReceivedNovember22,2012.

AcceptedforpublicationFebruary23,2013.

AddresscorrespondenceandreprintrequeststoBiaoCheng,MD,PhD,

DepartmentofPlasticSurgery,GuangzhouGeneralHospitalofGuangzhouMilitaryCommand,Guangzhou,GuangdongProvince,510010,PRChina;E-mail:chengbiaocheng@sohu.comTheauthorsreportnoconflictsofinterest.Copyright*2013byMutazB.Habal,MDISSN:1049-2275

DOI:10.1097/SCS.0b013e31828f2d8a

FIGURE2.Patient2:alargemalignantulcerintherighttemporozygomaticareaandcheekofthefaceinAPview(A)andrightlateralview(B).

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*2013MutazB.Habal,MD

Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

TheJournalofCraniofacialSurgery

&Volume24,Number4,July2013

BriefClinicalStudies

excellentpliability,andhassafeirrigation.One-stagesurgeryshouldbeconsideredpreferentiallybecauseitmayreducetheriskoftumorextendingandthehazardtopatients.Mostimportantly,thefunctionalandaestheticresultsweresatisfactoryforthepatientandforus.

REFERENCES

1.BrandD,AckermanAB.Squamouscellcarcinoma,notbasalcellcarcinoma,isthemostcommoncancerinhumans.JAmAcadDermatol2000;42:523Y526

2.SchaeferSD,ByrdHS,HolmesRE.Foreheadandscalpreconstructionafterwide-fieldresectionofskincarcinoma.ArchOtolaryngol1980;106:680Y684

3.DegnerDA.Facialreconstructivesurgery.ClinTechSmallAnimPract2007;22:82Y88

4.PinarYA,GovsaF.Anatomyofthesuperficialtemporalarteryanditsbranches:itsimportanceforsurgery.SurgRadiolAnat2006;28:248Y253

FIGURE3.Patient2:postoperativeresultaftertheforeheadflaprotatedandrepaired1monthlater;APview(A)andrightlateralview(B).

covereddirectlybyadjacenttissue.Otherwise,theidealsubstitutionisaforeheadflap,whichprovidesagoodskincolormatchingandanenhancedcosmeticresult.Theuseofforeheadflapsforfacialrecon-structionhasbeenpracticedformorethan100years.3Becauseitalwayscontainsthefrontalismuscleandisnourishedbytheperfo-ratingbloodvesselsfromthismuscle,theforeheadflapmaybecon-sideredtobeamyocutaneousflap.

Theforeheadflapthatisusedinreconstructivesurgeryismainlypreparedonthesuperficialtemporalarteryanditsbranches.Beforeflapplanning,thefrontalbranchofthesuperficialtemporalartery,thesupraorbitalartery,andthesupratrochlearanddorsalnasalar-teriesmustbepreciselylocatedusingpalpationorDopplerultra-sound.Thisimprovesflapsurvivalandallowsforanarrowerpediclebase,whichwillfacilitateflaprotationandgainflaplength.Besides,abetterunderstandingofthemidlineforeheadvascularityshouldallowmodificationofreconstructivetechniquesandreducepost-operativecomplications.4Thebloodsupplyofforeheadflapisfromthearterialtrafficbranchesbetweenthefrontalbranchof2sides,superficialtemporalarteryandthesupratrochlearartery,soitisthoughtriskyincon-ventionalideatodissectandrevolvethewholenondelayedforeheadflapfor1-stagerepair.However,whenweconsideredthatthelargemalignantulcerwasencroachingtheperiosteumandthelateralwalloftherightorbitalinthe60-year-oldpatient,theriskbecamenec-essarytotake,whichmeansmorecaremustbetakentokeepthebloodsupplyinthepedicleduringthedesignandoperationpro-gram.Consequently,itoffersthesameadvantagewithoutstaging,anditdefinitelycanbeusedinanysituationrequiringaforeheadflap.Forthepatientincase1,hehadbeentreatedwithChineseherbsfor1yearbeforehecametoourhospital,andthecancerousulcer-ationinthemidfacewasdeveloping.Consideringtheadvancedageandthebasicriskoftumorextending,1-stagerepairbecamethefirstchoiceforreconstructionofthenasaldefect

Besides,elderlypatientswithlargeadvancedcarcinomausuallyhaveotherdiseasesthatincreasetherisksundergeneralanesthesia,andtheaestheticrequirementforthemisinferior.Therefore,lengthyproceduressuchasfreeflapsortissueexpansionshouldbeavoided,andtheforeheadflapfor1-stagerepaircanbethebestchoiceinthesecircumstances.

ItisworthnotingthatmanyruralpatientsbelieveinherbaltreatmentinChina,justlikethepatientwithalargedefectonthenoseandperipheraltissuesinthemidface,resultinginthedevelopmentofcancerthatworsenbecauseofdelayedtreat-ment,whichmaymakeanemergencysurgeryforussometimes.

RealizationofMasticatoryMovementby3-DimensionalSimulationofthe

TemporomandibularJointandtheMasticatoryMuscles

Jong-TaePark,PhD,*Jae-GiLee,PhD,*Sung-YoonWon,PhD,*Sang-HeeLee,BS,*

Jung-YulCha,DDS,PhD,ÞHee-JinKim,DDS,PhD*Abstract:Masticatorymusclesarecloselyinvolvedinmastication,pronunciation,andswallowing,anditisthereforeimportanttostudythespecificfunctionsanddynamicsofthemandibularandmasticatorymuscles.However,theshortnessofmusclefibersandthediversityofmovementdirectionsmakeitdifficulttostudyandsimplifythedynamicsofmastication.Thepurposeofthisstudywastouse3-dimensional(3D)simulationtoobservethefunctionsandmove-mentsofeachofthemasticatorymusclesandthemandiblewhilechewing.Tosimulatethemasticatorymovement,computedtomo-graphicimagesweretakenfromasingleKoreanvolunteer(30-year-oldman),andskullimagedatawerereconstructedin3D(Mimics;Materialise,Leuven,Belgium).The3D-reconstructedmasticatory

Fromthe*DivisionofAnatomyandDevelopmentalBiology,Departmentof

OralBiology,HumanIdentificationResearchCenter,BrainKorea21Project,and†DepartmentofOrthodontics,CollegeofDentistry,YonseiUniversity,Seoul,SouthKorea.ReceivedNovember22,2012.

AcceptedforpublicationFebruary23,2013.

AddresscorrespondenceandreprintrequeststoHee-JinKim,DDS,PhD,

Room601,DepartmentofOralBiology,CollegeofDentistry,YonseiUniversity,250Seongsanno,Seodaemun-gu,Seoul120-752,SouthKorea;E-mail:hjk776@yuhs.ac

SupportedbyagrantfromtheKoreaHealthTechnologyR&DProject,

MinistryforHealth,Welfare&FamilyAffairs,RepublicofKorea(A111690).

Theauthorsreportnoconflictsofinterest.Copyright*2013byMutazB.Habal,MDISSN:1049-2275

DOI:10.1097/SCS.0b013e31828f2d73

CONCLUSIONS

Whenagreatareaofthefacemustbereconstructedforhavingacancerousulceration,theskinofthetotalforeheadareacanbesuc-cessfullyusedbecauseitsskinhascolorandtexturethatmatch,has*2013MutazB.Habal,MD

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Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.